HIPAA Incident Report Form

Information you will need

• What’s the date this HIPAA incident report is being made?
• Who’s filing the report?
• What’s their title?
• What’s the date of the incident?
• At what time was the incident discovered?
• What’s the actual date the incident occurred? (if known)
• What time of day was the incident discovered?
• How was the incident discovered?
• Was SSN information compromised in the incident?
• Was date of birth (DOB) information compromised in the incident?
• Was patient address information compromised in the incident?
• Was medical information compromised in the incident?
• Was another type of information compromised in the incident?
• What type of information was compromised?
• What happened?
• Who violated patient information? (if known)
• What’s the violator's job title? (if applicable)
• Were any containment measures made?
• What containment measures were made? (if applicable)
• Is there any other information that should be provided?
• What other information should be included in this report? (if applicable)
• Who received this report?
• What action was taken?
• Were any services permanently impacted?

…and 7 more fields in the PDF.

The form includes 2 signature lines.